Helping patients get home to heal

Case managers like Vonnie Coover-Stone help smooth the transition from hospital to home.

Entering a hospital is basically a simple process. You’re sick or injured, or need a surgical procedure — doctors diagnose you, and a care team checks you in and works to make you well. But leaving the hospital is much more complicated — and that’s where a case manager takes over.

The main job of a case manager is to prepare you to go home and make sure you have what you need there and that you won’t need to come back. The function of a hospital is to perform those critical functions that a patient can’t do for themselves; as soon as that patient is well enough to go home, the end goal is achieved.

“As good as our care is in the hospital,” says Vonnie Coover-Stone, case manager at Sharp Coronado Hospital, “we all know that the best place to heal is at home. There’s less risk of infection, and the comfort of familiar surroundings and loved ones to help you get better faster.”

As the patient prepares to leave the hospital, the case manager looks at all aspects of that patient’s personal situation:

Does he or she need a follow-up appointment soon with the doctor or surgeon?

Is a home health service such as physical therapy needed?

What medications have been prescribed, and will the patient be able to get (and afford) them?

Is there someone at home who will help in recovery, or is there a need for aftercare at a skilled nursing facility or hired in-home caregivers?

Is there insurance or other assistance that will help cover the costs of care after the hospital stay?

“We meet with each patient personally,” says Coover-Stone, “and then we develop a discharge plan with the patient, their family and other caregivers. Instructions for aftercare can be confusing, so our aim is to make them easily understood and simple to follow.”

Discharge instructions are delivered both verbally and in writing for the patient and caregivers to follow. Once the patient goes home, an administrative liaison makes follow-up calls to check on the patient.

“Sometimes patients don’t follow the plan after they go home,” says Coover-Stone. “We make it as clear and simple as we can, and hope they’ll be responsible partners in their own recovery.”

“We love our patients. But as strange as it might sound, once they leave, we hope they don’t have to come back, because that means they’re healthy and well.”